Citation Nr: 21022153 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 14-34 607 DATE: April 14, 2021 ORDER Entitlement to service connection for a gastrointestinal disorder other than gastroesophageal reflux disease (GERD), to include hemorrhoids, is granted. Entitlement to service connection for a low back condition is denied. Entitlement to service connection for a cervical spine condition is denied. FINDINGS OF FACT 1. The evidence is at least in equipoise as to the question of whether the Veteran’s gastrointestinal condition other than GERD is attributable to his exposure to environmental hazards while in service in the Southwest Asia theater of operations. 2. The competent evidence of record does not demonstrate that the Veteran’s low back and cervical spine symptomatology, now characterized as lumbar spine degenerative arthritis, is attributable to service, to include as due to exposure to environmental hazards in the Southeast Asia theater of operations; furthermore, the symptomatology is fully accounted for by the diagnosed condition, and is not a manifestation of a chronic, undiagnosed illness other than fibromyalgia. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a gastrointestinal condition other than GERD, to include hemorrhoids, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for a low back condition, to include as a manifestation of a chronic undiagnosed illness attributable to service in the Southeast Asia theater of operations, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317. 3. The criteria for entitlement to service connection for a cervical spine condition, to include as a manifestation of a chronic undiagnosed illness attributable to service in the Southeast Asia theater of operations, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107; 38 C.F.R. §§ 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1986 to September 1986, in July 1987, and from December 1990 to May 1991, including service in the Gulf War. These matters were last before the Board in June 2018, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. Following the issuance of a January 2021 supplemental statement of the case continuing the denial of all three claims, the case was returned to the Board for its adjudication. In view of the facts found, the Board has bifurcated the prior claim of entitlement to service connection for muscle and joint pain as two separate claims seeking entitlement to service connection for a low back condition and a cervical spine condition, respectively. Service Connection Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service.  Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).    Furthermore, certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause.  38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2012); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a).   Service connection may be established on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1) (VA has adopted an interim final rule extending this date to December 31, 2021). The predicate requirement for entitlement to service connection on this presumptive basis is that the symptomatology results from either (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). 1. Gastrointestinal disorder other than GERD, to include hemorrhoids The Veteran has filed a claim seeking entitlement to service connection for a stomach or bowel disorder and characterized that stomach or bowel disorder variously as hemorrhoids and acid reflux disease. While on appeal from the Board, in a January 2021 rating decision the AOJ granted entitlement to service connection for GERD effective February 24, 2011, the date of the original claim seeking service connection for a stomach or bowel disorder. The AOJ also promulgated the January 2021 supplemental statement of the case continuing the denial of the claim of entitlement to hemorrhoids separate from the GERD. As such, the Board may properly adjudicate the service connection claim for hemorrhoids and must determine whether service connection is warranted for hemorrhoids as a distinct disability. To that end, the question for the Board is whether a gastrointestinal condition other than GERD, to include hemorrhoids, began during service or is at least as likely as not related to an in-service injury, event or disease. After consideration of the record, the Board finds that the evidence is at least in equipoise as to whether the diagnosed hemorrhoids are attributable to service; as such, service connection for the gastrointestinal condition is warranted. A review of available service treatment records shows that the Veteran was evaluated with hemorrhoids in December 1990 and again in March 1991. The March 1991 outpatient note indicates that the Veteran first experienced the hemorrhoids in November 1990 while stationed at Camp Lejeune. The claims file contains a copy of a Gulf War Veterans Health Questionnaire dated in December 1995, wherein the Veteran reported experiencing severe stomach or digestive system problems, to specifically include diarrhea, constipation, abdominal gas and pain. Thereafter, on a March 1996 health questionnaire prepared for his private healthcare provider, the Veteran reported a history of experiencing hemorrhoids. He repeated this same history on a subsequent September 1999 health questionnaire. VA medical records show that the Veteran has been followed for hemorrhoids through VA as early as August 2010; subsequent records show that hemorrhoids has continued to be listed as an active problem. A January 2011 outpatient record indicates that the Veteran underwent hemorrhoidectomy surgery, with a corresponding note reflecting that he reported experiencing longstanding constipation with hemorrhoids. In a May 2011 statement, the Veteran reported that he had been experiencing hemorrhoids since the condition first developed in service in December 1990. It was his belief that the hemorrhoids began due to stress he experienced as well as his diet while in service in the Southeast Asia theater of operations. He also shared his contention that the condition was attributable to his exposure to environmental hazards while in service in the Southeast Asia theater of operations. Pursuant to the Board’s June 2018 remand instructions, the Veteran was afforded a May 2019 VA intestinal conditions examination, during which it was noted that he was diagnosed with hemorrhoids in 2008 following a colonoscopy. Diagnostic testing confirmed that the Veteran did have external hemorrhoids as well as alternating diarrhea and constipation. Before the claim was returned to the Board, the AOJ secured a series of addendum opinions dated in October 2020 regarding the etiology of the hemorrhoid condition. First, a VA examiner opined that it was less likely than not that the hemorrhoid condition was secondary to service-connected posttraumatic stress disorder (PTSD) on the grounds that medical literature did not support a connection between PTSD symptomatology and the development of hemorrhoids. That same examiner opined that it was less likely than not that the Veteran’s hemorrhoid condition was incurred in service, as they found no evidence that the Veteran had been diagnosed with internal hemorrhoids in service. Finally, the examiner also found that it was less likely than not that hemorrhoid condition was attributable to his exposure to environmental hazards during his service in the Southeast Asia theater of operations. This was on the grounds that medical literature did not support a connection between acknowledged Gulf War chemical and environmental exposures and the development of hemorrhoids. In a second addendum opinion dated in January 2021, a VA examiner reevaluated the evidence of record and found that it was at least as likely as not that the Veteran’s change in bowel habits was caused by his in-service exposure to environmental hazards from his service in the Gulf War. The examiner referred to internal VA memoranda which summarized medical literature that suggested a connection between military service in the Southeast Asia theater of operations and the development of gastrointestinal disorders. The three October 2020 VA opinions are deficient because the examiner relied on an inaccurate understanding of the Veteran’s medical history, namely, that he had not been diagnosed with hemorrhoids in service despite clear documentation to the contrary. While the Board would typically remand for correction of this error, instead the Board gives deference to the January 2021 addendum opinion that found it at least as likely as not that the Veteran’s changes in bowel habits (which the Board takes to include the currently diagnosed hemorrhoid condition) was caused by his exposure to environmental hazards while in service in the Southeast Asia theater of operations. As such, the evidence in support of a determination that the Veteran’s hemorrhoid condition is attributable to his exposure to environmental hazards during service in the Southeast Asia theater of operations is at least in equipoise with the evidence tending to refute such a determination. As such, service connection is warranted for a gastrointestinal condition other than GERD, to include hemorrhoids. The claim is thus granted. 2. Low back condition The Veteran contends that he has a low back condition distinct from his service-connected fibromyalgia that is attributable to service. Specifically, the Veteran contends that his low back symptomatology is either a manifestation of an undiagnosed chronic multi-symptom illness, other than fibromyalgia, that is attributable to his service in the Southwest Asia theater of operations, or that the now diagnosed lumbar spine condition is directly attributable to his service, to include his exposure to environmental hazards while serving in Southwest Asia. The initial question for the Board is whether the Veteran has a diagnosable condition manifested by lumbar spine symptomatology that began during service or is at least as likely as not related to an in-service injury, event, or disease, to include exposure to environmental or chemical hazards in service. In the alternative, the question for the Board is whether the Veteran has lumbar spine symptomatology resulting from an undiagnosed illness or a medically unexplained chronic multisystem illness other than fibromyalgia. With regard to the first query, while the Veteran is currently diagnosed with degenerative disc disease of the lumbar spine, the Board concludes that the preponderance of the evidence is against a finding that this condition is attributable to service. 38 C.F.R. § 3.303(a), (d). As for the second query, the Board concludes that the Veteran has a confirmed diagnosis that accounts for the lumbar spine symptomatology. As such, it does not qualify for presumptive service connection for an undiagnosed chronic condition attributable to environmental exposures in Southwest Asia. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A review of the Veteran’s service treatment records does not reflect that the Veteran ever reported experiencing any low back symptomatology during service. On a December 1990 dental health questionnaire he did note a history of experiencing painful joints but did not specify that it was his back that hurt. No spine abnormalities were recorded on any of the periodic in-service examinations or Reports of Medical History. Post-service, the claims file contains a copy of a Gulf War Veterans Health Questionnaire dated in December 1995 in which the Veteran reported experiencing painful muscles and joints since service. Thereafter, on a January 1996 private health questionnaire prepared for his job, he again reported a history of experiencing back pain, painful joints, numbness, and weakness. In a March 2001 evaluation with the Pain Management Center of Roanoke, the Veteran reported that he was involved in a motor vehicle accident in April 2000 during which he sustained an injury to his lower back. He also detailed an incident about two months later (so in June 2000) while working when two individuals fell on top of him. According to the Veteran, he had been experiencing low back pain ever since the motor vehicle accident. After an in-person examination, the Veteran was diagnosed with lumbar degenerative disc disease as well as lumbar facet joint arthropathy and myofascial pain syndrome. Subsequent medical records from the Pain Management Center show continued treatment for low back pain A January 2002 pain clinic note reflects that the Veteran reported experiencing chronic back pain ever since the April 2000 motor vehicle accident. The assessment was diffuse myofascial pain, as well as minimal degenerative disk disease. However, the examiner specifically noted that the degenerative disc disease did not explain the Veteran’s pain complaints. Medical records dating from September 2002 show that the Veteran sought treatment for chronic back pain that he attributed to a motor vehicle accident that occurred in April 2000. After a thorough evaluation the Veteran was diagnosed with post-traumatic myofascial pain syndrome alone with chronic pain syndrome. A March 2010 VA outpatient note indicated that the Veteran sought treatment for recent onset localized lower back pain. A corresponding radiographic examination revealed mild facet arthrosis. Thereafter, during an April 2010 physical therapy consultation the Veteran again detailed that his low back pain had begun only six to eight months prior without any preceding injury. However, a July 2010 neurology consultation note shows that the Veteran reported a history of a motor vehicle accident in 2000 during which he sustained a back injury. According to the Veteran, he had been experiencing low back pain ever since this incident. An April 2016 neurology procedure note indicates that the Veteran was undergoing a course of trigger point injection therapy to relieve chronic lumbar pain. More recently, private treatment records from Acupuncture Wellness Center dated in 2018 reflect that he reported experiencing low back pain for the past 18 years following the April 2000 motor vehicle accident. Pursuant to the Board’s June 2018 remand instructions, the Veteran was scheduled for a May 2019 VA back examination, during which he reported experiencing low back pain since the previous motor vehicle accident (erroneously noted to have occurred in 2004). After a thorough evaluation, to include radiographic examinations, the examiner set forth a diagnosis of degenerative arthritis of the lumbar spine. In an August 2019 addendum opinion, the examiner first clarified that the Veteran’s low back pain was fully attributable to the degenerative arthritis diagnosed on the prior May 2019 examination. The examiner then opined that it was less likely than not that the degenerative arthritis was attributable to service on the grounds that the current complaints of low back pain began following the documented motor vehicle accident. Upon review of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for a low back condition. To begin, the presumptive portions of 38 C.F.R. § 3.317(a)(1) do not apply, as the Veteran’s low back symptomatology has been attributed to his diagnosed degenerative arthritis of the lumbar spine. Moreover, the August 2019 VA examiner confirmed that the Veteran’s history of low back symptomatology was fully accounted for by the diagnosed condition. Finally, the Veteran is separately service connected for fibromyalgia. As such, to provide for service connection for a distinct low back disability manifested by muscle pain that is already being compensated for would violate the rule against pyramiding. 38 C.F.R. § 4.14. Accordingly, the Board finds that service connection for any low back symptomatology on a presumptive basis is denied. The Veteran has generally asserted that his low back symptomatology manifested in service and has continued to the present day. He is competent to testify as to when his symptoms began. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, service treatment records are absent any documentation of complaints of or treatment for low back symptomatology. This weighs against a determination that the low back symptomatology arose during service and continued thereafter. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The Board also notes that it finds the opinion of the May 2019 VA examiner to be highly probative as to the ultimate determination of whether the diagnosed low back condition was incurred in or is otherwise attributable to service. Specifically, the examiner reviewed the claims file and referred to the Veteran’s medical history in finding that there was no evidence of a chronic low back condition in service and after service until after he was involved in the motor vehicle accident in April 2000. As such, the August 2019 opinion that it was less likely than not that the low back condition was attributable to service is highly probative. Sklar v. Brown, 5 Vet. App. 140 (1993). In consideration of the lack of a diagnosis of a chronic condition in service, and in light of the highly probative VA examiner opinion, the Board finds that the preponderance of the evidence is against the claim of service connection on a direct basis under 38 C.F.R. § 3.303(a). Furthermore, there is no documentation of the Veteran having experienced a diagnosable chronic low back condition in service, and there was no definitive diagnosis until after the April 2000 motor vehicle accident. As such, the Board also finds that service connection for a low back condition based on continuity of symptomatology under 38 C.F.R. § 3.303(b) is also denied.  The Veteran may still be entitled to service connection for a low back condition if all of the evidence establishes that the condition is otherwise attributable to an in-service occurrence. 38 C.F.R. § 3.303(d). The Veteran specifically contends that his low back condition is attributable to his exposure to environmental hazards while in service in the Southeast Asia theater of operations. However, he has presented no objective medical evidence to support this contention. Moreover, there is no evidence in the record showing that he has the medical training, credentials, or other expertise to competently conclude that his low back symptomatology is due to his exposure to any environmental hazards while in service. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). This theory of entitlement was also dismissed in the highly probative August 2019 VA examiner opinion. There is no positive evidence in the claims file to support that the low back condition that was diagnosed several years after service is attributable to an in-service injury, event or disease, to include any exposure to environmental hazards in the Southeast Asia theater of operations. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). 3. Cervical neck condition The Veteran contends that he has a cervical spine condition distinct from his service-connected fibromyalgia that is attributable to service. Specifically, the Veteran contends that his cervical spine symptomatology is either a manifestation of an undiagnosed chronic multi-symptom illness, other than fibromyalgia, that is attributable to his service in the Southwest Asia theater of operations, or that the now diagnosed cervical spine condition is directly attributable to his service, to include his exposure to environmental hazards while serving in Southwest Asia. The initial question for the Board is whether the Veteran has a diagnosable condition manifested by cervical spine symptomatology that began during service or is at least as likely as not related to an in-service injury, event, or disease, to include exposure to environmental or chemical hazards in service. In the alternative, the question for the Board is whether the Veteran has cervical spine symptomatology resulting from an undiagnosed illness or a medically unexplained chronic multisystem illness other than fibromyalgia. With regard to the first query, while the Veteran is currently diagnosed with degenerative disc disease of the cervical spine, the Board concludes that the preponderance of the evidence is against a finding that this condition is attributable to service. 38 C.F.R. § 3.303(a), (d). As for the second query, the Board concludes that the Veteran has a confirmed diagnosis that accounts for the cervical spine symptomatology. As such it does not qualify for presumptive service connection for an undiagnosed chronic condition attributable to environmental exposures in Southwest Asia. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). A review of the Veteran’s service treatment records does not reflect that the Veteran ever reported experiencing any cervical spine symptomatology during service. On a December 1990 dental health questionnaire, he did note a history of experiencing painful joints but did not specify that it was his neck that hurt. No neck or spine abnormalities were recorded on any of the periodic in-service examinations or Reports of Medical History. Post-service, the claims file contains a copy of a Gulf War Veterans Health Questionnaire dated in December 1995, in which the Veteran reported experiencing painful muscles and joints since service. Thereafter, on a January 1996 private health questionnaire prepared for his job, he again reported a history of experiencing back pain, painful joints, numbness, and weakness. Treatment records beginning in September 2000 from the Lewis-Gale Center for Outpatient Rehabilitation show that the Veteran reported experiencing chronic neck pain ever since an April 2000 motor vehicle accident. After an initial evaluation, the impression was a cervical strain. Subsequent records do show continued treatment for neck pain without a formal diagnosis. In a March 2001 evaluation with the Pain Management Center of Roanoke, the Veteran reported that he was involved in a motor vehicle accident in April 2000 during which he sustained an injury to his neck. He also detailed an incident about two months later (so in June 2000) while working when two individuals fell on top of him. According to the Veteran he had been experiencing neck pain ever since the motor vehicle accident. After an in-person examination, the Veteran was diagnosed with cervical degenerative disc disease as well as cervical facet joint arthropathy and myofascial pain syndrome. Subsequent medical records from the Pain Management Center show continued treatment for neck pain. An August 2003 initial consultation reflects that the Veteran first sought treatment through the VA medical system with complaints of neck pain and stiffness that he attributed to an unspecific car accident (assumedly, the April 2000 motor vehicle accident). He reported during the consultation that he was without symptoms prior to the motor vehicle accident. No formal diagnosis was set forth at that time. During a June 2008 pain consultation at his local VA medical center, the Veteran reported that he had been experiencing chronic neck pain ever since the April 2000 motor vehicle accident. A corresponding June 2008 radiographic examination revealed minimal degenerative disc disease and degenerative joint disease at C6-C7. After completing the evaluation, the examiner did not set forth a formal diagnosis to account for the neck pain. A March 2010 VA outpatient note indicated that the Veteran sought treatment for recent onset localized lower back pain. A corresponding radiographic examination revealed mild fact arthrosis. Thereafter, during an April 2010 physical therapy consultation, the Veteran again detailed that his low back pain had begun only six to eight months prior without any preceding injury. However, a July 2010 neurology consultation note shows that the Veteran reported a history of a motor vehicle accident in 2000, during which he sustained a back injury. According to the Veteran, he had been experiencing neck pain ever since this incident. An April 2016 neurology procedure note indicates that the Veteran was undergoing a course of trigger point injection therapy to relieve chronic cervical pain. More recently, private treatment records from Acupuncture Wellness Center dated in 2018 reflect that the Veteran reported experiencing neck pain for the past 18 years following the April 2000 motor vehicle accident. Pursuant to the Board’s June 2018 remand instructions, the Veteran was scheduled for a May 2019 VA neck examination, during which he reported experiencing neck pain since the previous motor vehicle accident (erroneously noted to have occurred in 2004). After a thorough evaluation, to include radiographic examinations, the examiner set forth a diagnosis of degenerative arthritis of the cervical spine. In an August 2019 addendum opinion, the examiner first clarified that the Veteran’s neck pain was fully attributable to the degenerative arthritis diagnosed on the prior May 2019 examination. The examiner then opined that it was less likely than not that the neck condition was attributable to service on the grounds that the current complaints of neck pain began following the documented motor vehicle accident. Upon review of the record, the Board finds that the preponderance of the evidence is against a determination that service connection is warranted for a cervical spine condition. To begin, the presumptive portions of 38 C.F.R. § 3.317(a)(1) do not apply, as the Veteran’s cervical spine symptomatology has been attributed to his diagnosed degenerative arthritis of the cervical spine. Moreover, the August 2019 VA examiner confirmed that the Veteran’s history of cervical spine symptomatology was fully accounted for by the diagnosed condition. Finally, the Veteran is separately service-connected for fibromyalgia, and so to provide for service connection for a distinct cervical spine disability manifested by muscle pain that is already being compensated for would violate the rule against pyramiding. 38 C.F.R. § 4.14. As such, the Board finds that service connection for any cervical spine symptomatology on a presumptive basis is denied. The Veteran has generally asserted that his cervical spine symptomatology manifested in service and has continued to the present day. He is competent to testify as to when his symptoms began. Layno, supra. However, service treatment records are absent any documentation of complaints of or treatment for cervical spine symptomatology, which weighs against a determination that the cervical spine symptomatology arose during service and continued thereafter. See Buchanan, supra. The Board also notes that it finds the opinion of the May 2019 VA examiner to be highly probative as to the ultimate determination of whether the diagnosed cervical spine condition was incurred in or is otherwise attributable to service. Specifically, the examiner reviewed the claims file and referred to the Veteran’s medical history in finding that there was no evidence of a chronic cervical spine condition in service and after service until after the Veteran was involved in the motor vehicle accident in April 2000. As such, the August 2019 opinion that it was less likely than not that the cervical spine condition was attributable to service is highly probative. Sklar, supra. In consideration of the lack of a diagnosis of a chronic condition in service, and in light of the highly probative VA examiner opinion, the Board finds that the preponderance of the evidence is against the claim of service connection on a direct basis under 38 C.F.R. § 3.303(a). Furthermore, there is no documentation of the Veteran having experienced a diagnosable chronic cervical spine condition in service, and there was no definitive diagnosis until after the April 2000 motor vehicle accident. As such, the Board also finds that service connection for a cervical spine condition based on continuity of symptomatology under 38 C.F.R. § 3.303(b) is also denied.  The Veteran may still be entitled to service connection for a cervical spine condition if all of the evidence establishes that the condition is otherwise attributable to an in-service occurrence. 38 C.F.R. § 3.303(d). The Veteran specifically contends that his cervical spine condition is attributable to his exposure to environmental hazards while in service in the Southeast Asia theater of operations. However, he has presented no objective medical evidence to support this contention, and there is no evidence in the record showing that he has the medical training, credentials, or other expertise to competently conclude that his cervical spine symptomatology is due to his exposure to any environmental hazards while in service. Jandreau, supra. This theory of entitlement was also dismissed in the highly probative August 2019 VA examiner opinion, and there is no positive evidence in the claims file to support that the cervical spine condition that was diagnosed several years after service is attributable to an in-service injury, event or disease, to include any exposure to environmental hazards in the Southeast Asia theater of operations. As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b). A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.